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DOCUMENTATION AND REPORTING
ANJANA THOMAS
Documentation
 Any written or electronically generated information
 Describe the care or service provided
 It is an accurate account of what occurred and when it
occourred
Nursing documentation
 Assessment of patient health status, nursing interventions
 Care plan/ health plan
 Information reported to the physician
 Advocacy undertaken by the nurse on behalf of the patient
Record
 Clinical, scientific, administrative and permanent legal
documentation of information related to patient health care
Purpose of recording
 Communication
 Quality of care
 Legal documentation
 Planning patient care
 Audit
 Research
 Reimbursement
Confidentiality
 Patient confidentiality – legal consideration
 The health insurance portability and accountability act (HIPAA)
HIPPA violations
 Gossiping / taking about the patient
 Mishandling the medical record
 Leaving medical record unsecured
 Illegally or unauthorized assessing of patient record
 Sharing information
 Texting or e-mailing on an unencrypted device
 Sharing information on social media
Types of patient record
 Patient clinical record
 Medical / nursing record
 Ward record
 Administrative record
Patient clinical record
 Knowledge of events involved in the patient’s illness, progress, care
provided
 Patient’s identification and demographic data
 Present complaints
 Informed consent for treatment and procedure
 Admission nursing history
 Family history
 Physical examination findings
 Nursing diagnosis and problems
 Nursing care plan
Patient clinical record
 Medical history
 Tentative diagnosis
 Medical diagnosis
 Therapeutic orders
 Treatment given
 Progress notes
 Supportive care given
 Report of diagnostic studies
 Final diagnosis
 Patient education
 Summary of operative procedures discharge plan and summary
 Any specific instructions
Medical records
 Legal document providing information of a patient’s medical history and
care by physicians, nurse practitioners and other health care members
 Identification
 Patient health history
 Medical examination findings
 Lab test result, medication prescribed referral orders
 Health instruction to the patient
Nursing records
 Progress notes
 Work sheets and kardexes
 Flow sheets
 Intake/ out put section
 Vital signs
 Patient care plan
 E- health record
Guidelines for nurse using electronic
records
 Never reveal personal password and ID no
 Immediate inform your supervisor if there is suspicion
 Change password
 Choose password that are not easily deciphered
 Log off when not using
 Maintain confidentiality
 Locate printers in secured areas
 Retrieve printed information immediately
 Protect patient information
 Use system with security
Ward record
 Record of reduction or increase in bed
 Admission and discharge
 Linen record
 Indent book
 Rounds book
 Attendance book
 Record book
 Treatment book
Administrative record
 Treatment
 Admission
 Equipment losses and replacement
 Personal performance
 Organizational record
METHODS OF DOCUMENTATION
 1. Narrative
 2. problem oriented medical record
 3. SOAPIER
 4. PIE
 5. Changing by exception
Narrative
 Traditional method
 Story like format
 Specific to patient condition and care
 Data is recorded with out an organization frame work
Problem oriented medical record
 Single list of patient problem
 Nursing process forms the basis for the POMR method
 Emphasis on patients problem
Advantage of POMR
 Give emphasis to patient’s perception of their problems
 Requires continues evaluation and revision of the care plan
 Greater continuity of care among health care team members
 Enhance effective communication
 Increase efficacy in gathering date
 Provide easy to read information in chronological order
 Reinforces use of the nursing process
Components of POMR
 Database
 Problem list
 Plan of care
 Progress notes
 SOAP
 Subjective data
 Objective data
 Assessment
 Planning
SOAPIER
 Structured way in which narrative progress notes are written by the health care team
 S- Subjective data – Information obtained from the patient
 O- Objective data - information measured or observed
 A- Assessment – interpretation/conclusion drawn about the sub/obj data
 P- Planning – Plan of care designed for resolve the stated problem
 I- Intervention -Refers to the specifics that have been performed by caregiver
 E- Evaluation – response to the nursing intervention
 R- Revision – care plan modification modifications suggested by the evaluation
Problem intervention evaluation (PIE)
 Problem, intervention and evaluation of nursing care
 Consist of a patient care assessment flow sheet and progress notes
 Flow sheet uses specific assessment criteria in a particular format
 Human needs or functional health pattern
 Notes are numbered or labeled according to the patients problem
 Resolved problems are dropped from the daily documentation
Focus charting
 Notes that include data, both subjective and objective
 Action or nursing intervention
 Response of the patient
 Notes are structured according to the patient’s concern
 Written in accordance with the nursing process
 Sign or symptoms
 Condition
 Nursing diagnosis
 Behavior
 Significant event
 Change in patient’s condition
Charting by exception
 Abnormal or significant findings or exceptions to norms are recorded
 Flow sheet : graphic record, fluid balance record, daily care record, patient teaching
record
 Standards of nursing care : reference to the agencies printed standards of nursing
practice
 Bedside assess to chart form, kept at the patient’s bedside to allow immediate
recording
Computerized documentation
Computerized documentation
 Used in
 Clinical system
 Management information system
 Educational system
Advantages
 Legibility of information
 Increased time efficacy, consistency and accuracy
 Data base for research
 Link various sources
 Patient information, requests and result are sent and received quickly
 Standard terminology improve communication
Disadvantages
 No privacy if security measures are used
 System failure
 Expensive
 Need training whenever an updating system installed
Electronic health record
 Systematic collection of electronic health information about individual patients
Purpose
 Automation and streaming of the workflow in health care setting and
increase safety through evidence- based decision support, quality
management, and outcomes reporting
Advantage
 Instant access of all patient information
 Improved efficiencies and provide quality of care
 Help in decision making and ensure that the quality of services
 Maintain highest professional standards
Functions
 Health data and information
 Order management
 Result management
 Decision support
 Electronic connectivity and communication
 Patient support
 Administrative process
 Reporting
Barriers of EHR
 Technical problems
 Resource matter
 Financial concern - products are expensive and require a major
investment.
 Training
 Concern with privacy
Common record keeping forms
Guidelines for documentation
 Date and time
 Timing
 Legibility
 Permanence
 Correct spelling
 Signature
 Accuracy
 Sequence
 Appropriateness
 Completeness
 Conciseness
 Accepted terminology
 Legal prudence
 Do not identify the chart by room
number
 Accurate notation
 Avoid general words
DO’S DON’T’S
• Should be patient’s name on every sheet
• Check file before any care and charting
• Good skill in English language
• Use concise phrases in notes
• Make entries in serial order
• Use accepted abbreviations
• Should not be torn, back date or rewrite on
the previously added document
• Not to use medical terms, if should not know
exactly
• Not to chart for other staff
• Not to leave the space in between charting
REPORTING
 Reports are oral, written or audio taped exchange of
information about the patient.
 It provides information on existing condition of patient.
 Common reports given by nurse include
 Shift report
 Transfer report
 Telephone report
 Incident report
 Reports can be compiled daily, weekly, monthly, quarterly and
annually.
Guidelines for reporting
 Factual
 Accurate
 Complete
 Current issue
 Organization
Factual
 Report must consist of objective information
 Observe using the senses
 When reports do not have factual observed information, they cannot be accepted
 The exact quotation or words used by the patient must be reported.
Accurate
 Whenever reporting any quantity measures report exact amount
 Eg: patient drink adequate amount of water – patient drink 150ml of water
 Data should be concise, clear and easy to understand
Complete
 Must be complete containing all essential information
 Care plan information to be entered
 Patient health problem and nursing activities to recored
Current
 Information entered in a timely basis.
 24 hour / 12 hour time cycle
 13.00 or 1 pm
Organized
 Arranged in logical order
 Order of nursing process
 Assessment, diagnose, goal, plan, implementation, evaluation
Criteria of a Good Report
 It can be made promptly
 It should be clear, concise and complete
 All identified data should be included
 Easy to understand
 Important points should be emphasized
Purpose of writing report
 To show the kind and quantity of service rendered over to a specific
period
 Show the progress in reaching goals
 To study health condition
 Interpret the services to the public and to other agencies
Types of reporting
 1. change in shift report
 It is a report given by a nurse to another due to change in shift
 Provide continuity of care by providing quick summary of assigned patient
 Includes diagnosis of patient, present health condition, treatment and
medication.
 Both the nurses while giving report should assess the patient together
 Types : oral and written report
 2. Telephone report
 Include communication about patient’s transfer to another ward and
about patient’s health status
 Common – nurse to nurse, nurse to laboratory, nurse to physician
 Telephone report should be documented, include time of call, who made the
call and to whom information is given.
 3. Transfer report
 Related to shifting the patient from one unit to another
 Transfer reports provide continuity of care by providing the
information on telephone.
 It include :
Patient name, age and diagnosis.
Current health status of patient
Any procedure or intervention that need to be performed after transfer
patient to other ward or unit.
 4. Incident reports or Accident reports
 Should be complete, clear and accurate as these are legal documents
 Filled in the office of nursing superintendent
 Studied for prevention of such accidents in future
 5. Intra division report
 Nurse incharge and bedside nurse
 Between nurse incharge and physician
 Head nurse and administrative supervisors
 6. Inter department report
 Reports shared with other department
 Report of patient discharged are send to admission, business office and
information desk
Importance
 Employer – Employment, promotion, disposition
 Court of law for various purpose
 Used for a job and leave from work place
 Lawyers used for compensation and liability
 Damage against negligent act
 Execution of will
 Medico-legal reasons
 For use in consumer court
Guideline – minimize legal liabilities
 Patient identification data in all pages
 Write clearly and appropriately
 Facts should be based on the observation, conversation and action.
 Select only relevant facts
 Records should be neat, clean, complete and uniform
 Record all telephonic conversation and follow up
 Use standers terminologies and abbreviations
 Do not erase or change any entries
 No individual sheet should be separated
 Correct all mistake as soon as possible
 Record procedure after completion
 Never leave vacant space
 Do not write judgement comments
 Do not destroy the documents
Communication in health care team
 Face to face communication
 Written communication
 Consultation
 Referrals
Nursing informatics
 French word – informatique – computer science
 The use of computers technology to support nursing, including clinical practice,
administration, education and research
Goal
 To improve health of population, communities, families and individuals by
optimizing, information management and communication
 Use the technology in the direct provision of care, in establishing effective
administrative system
Functions
 To enhance patient care and nursing practice
 Way of keeping patient information properly organized
 Nurses to make notes that every one can assess
 Help with dosing instructions, staff assignment and lab results
 Help and to create nursing care plan
 Coordinated information help in decision making
Framework
 Data
 Information
 Knowledge
Importance of nursing informatics
 Increase the accuracy and completeness of nursing documentation
 Improves the nurses workflow
 Eliminate redundant documentation
 Automates the collection and reuse of nursing data
 Facilitates analysis of clinical data
 Access to resources and reference
 Beneficial to nurses and interdisciplinary team
 Administrative – support for cost saving and productivity goals
Application
 Nursing clinical practice – point of care system and clinical information
system
 Nursing administration
 Nursing education nursing research
Thank you….

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unit v documentation.pptx

  • 2. Documentation  Any written or electronically generated information  Describe the care or service provided  It is an accurate account of what occurred and when it occourred
  • 3. Nursing documentation  Assessment of patient health status, nursing interventions  Care plan/ health plan  Information reported to the physician  Advocacy undertaken by the nurse on behalf of the patient
  • 4. Record  Clinical, scientific, administrative and permanent legal documentation of information related to patient health care
  • 5. Purpose of recording  Communication  Quality of care  Legal documentation  Planning patient care  Audit  Research  Reimbursement
  • 6. Confidentiality  Patient confidentiality – legal consideration  The health insurance portability and accountability act (HIPAA)
  • 7. HIPPA violations  Gossiping / taking about the patient  Mishandling the medical record  Leaving medical record unsecured  Illegally or unauthorized assessing of patient record  Sharing information  Texting or e-mailing on an unencrypted device  Sharing information on social media
  • 8. Types of patient record  Patient clinical record  Medical / nursing record  Ward record  Administrative record
  • 9. Patient clinical record  Knowledge of events involved in the patient’s illness, progress, care provided  Patient’s identification and demographic data  Present complaints  Informed consent for treatment and procedure  Admission nursing history  Family history  Physical examination findings  Nursing diagnosis and problems  Nursing care plan
  • 10. Patient clinical record  Medical history  Tentative diagnosis  Medical diagnosis  Therapeutic orders  Treatment given  Progress notes  Supportive care given  Report of diagnostic studies  Final diagnosis  Patient education  Summary of operative procedures discharge plan and summary  Any specific instructions
  • 11. Medical records  Legal document providing information of a patient’s medical history and care by physicians, nurse practitioners and other health care members  Identification  Patient health history  Medical examination findings  Lab test result, medication prescribed referral orders  Health instruction to the patient
  • 12. Nursing records  Progress notes  Work sheets and kardexes  Flow sheets  Intake/ out put section  Vital signs  Patient care plan  E- health record
  • 13. Guidelines for nurse using electronic records  Never reveal personal password and ID no  Immediate inform your supervisor if there is suspicion  Change password  Choose password that are not easily deciphered  Log off when not using  Maintain confidentiality  Locate printers in secured areas  Retrieve printed information immediately  Protect patient information  Use system with security
  • 14. Ward record  Record of reduction or increase in bed  Admission and discharge  Linen record  Indent book  Rounds book  Attendance book  Record book  Treatment book
  • 15. Administrative record  Treatment  Admission  Equipment losses and replacement  Personal performance  Organizational record
  • 16. METHODS OF DOCUMENTATION  1. Narrative  2. problem oriented medical record  3. SOAPIER  4. PIE  5. Changing by exception
  • 17. Narrative  Traditional method  Story like format  Specific to patient condition and care  Data is recorded with out an organization frame work
  • 18. Problem oriented medical record  Single list of patient problem  Nursing process forms the basis for the POMR method  Emphasis on patients problem
  • 19. Advantage of POMR  Give emphasis to patient’s perception of their problems  Requires continues evaluation and revision of the care plan  Greater continuity of care among health care team members  Enhance effective communication  Increase efficacy in gathering date  Provide easy to read information in chronological order  Reinforces use of the nursing process
  • 20. Components of POMR  Database  Problem list  Plan of care  Progress notes  SOAP  Subjective data  Objective data  Assessment  Planning
  • 21. SOAPIER  Structured way in which narrative progress notes are written by the health care team  S- Subjective data – Information obtained from the patient  O- Objective data - information measured or observed  A- Assessment – interpretation/conclusion drawn about the sub/obj data  P- Planning – Plan of care designed for resolve the stated problem  I- Intervention -Refers to the specifics that have been performed by caregiver  E- Evaluation – response to the nursing intervention  R- Revision – care plan modification modifications suggested by the evaluation
  • 22. Problem intervention evaluation (PIE)  Problem, intervention and evaluation of nursing care  Consist of a patient care assessment flow sheet and progress notes  Flow sheet uses specific assessment criteria in a particular format  Human needs or functional health pattern  Notes are numbered or labeled according to the patients problem  Resolved problems are dropped from the daily documentation
  • 23. Focus charting  Notes that include data, both subjective and objective  Action or nursing intervention  Response of the patient  Notes are structured according to the patient’s concern  Written in accordance with the nursing process  Sign or symptoms  Condition  Nursing diagnosis  Behavior  Significant event  Change in patient’s condition
  • 24. Charting by exception  Abnormal or significant findings or exceptions to norms are recorded  Flow sheet : graphic record, fluid balance record, daily care record, patient teaching record  Standards of nursing care : reference to the agencies printed standards of nursing practice  Bedside assess to chart form, kept at the patient’s bedside to allow immediate recording
  • 26. Computerized documentation  Used in  Clinical system  Management information system  Educational system
  • 27. Advantages  Legibility of information  Increased time efficacy, consistency and accuracy  Data base for research  Link various sources  Patient information, requests and result are sent and received quickly  Standard terminology improve communication
  • 28. Disadvantages  No privacy if security measures are used  System failure  Expensive  Need training whenever an updating system installed
  • 29. Electronic health record  Systematic collection of electronic health information about individual patients
  • 30. Purpose  Automation and streaming of the workflow in health care setting and increase safety through evidence- based decision support, quality management, and outcomes reporting
  • 31. Advantage  Instant access of all patient information  Improved efficiencies and provide quality of care  Help in decision making and ensure that the quality of services  Maintain highest professional standards
  • 32. Functions  Health data and information  Order management  Result management  Decision support  Electronic connectivity and communication  Patient support  Administrative process  Reporting
  • 33. Barriers of EHR  Technical problems  Resource matter  Financial concern - products are expensive and require a major investment.  Training  Concern with privacy
  • 35. Guidelines for documentation  Date and time  Timing  Legibility  Permanence  Correct spelling  Signature  Accuracy  Sequence  Appropriateness  Completeness  Conciseness  Accepted terminology  Legal prudence  Do not identify the chart by room number  Accurate notation  Avoid general words
  • 36. DO’S DON’T’S • Should be patient’s name on every sheet • Check file before any care and charting • Good skill in English language • Use concise phrases in notes • Make entries in serial order • Use accepted abbreviations • Should not be torn, back date or rewrite on the previously added document • Not to use medical terms, if should not know exactly • Not to chart for other staff • Not to leave the space in between charting
  • 37. REPORTING  Reports are oral, written or audio taped exchange of information about the patient.  It provides information on existing condition of patient.  Common reports given by nurse include  Shift report  Transfer report  Telephone report  Incident report  Reports can be compiled daily, weekly, monthly, quarterly and annually.
  • 38. Guidelines for reporting  Factual  Accurate  Complete  Current issue  Organization
  • 39. Factual  Report must consist of objective information  Observe using the senses  When reports do not have factual observed information, they cannot be accepted  The exact quotation or words used by the patient must be reported.
  • 40. Accurate  Whenever reporting any quantity measures report exact amount  Eg: patient drink adequate amount of water – patient drink 150ml of water  Data should be concise, clear and easy to understand
  • 41. Complete  Must be complete containing all essential information  Care plan information to be entered  Patient health problem and nursing activities to recored
  • 42. Current  Information entered in a timely basis.  24 hour / 12 hour time cycle  13.00 or 1 pm
  • 43. Organized  Arranged in logical order  Order of nursing process  Assessment, diagnose, goal, plan, implementation, evaluation
  • 44. Criteria of a Good Report  It can be made promptly  It should be clear, concise and complete  All identified data should be included  Easy to understand  Important points should be emphasized
  • 45. Purpose of writing report  To show the kind and quantity of service rendered over to a specific period  Show the progress in reaching goals  To study health condition  Interpret the services to the public and to other agencies
  • 46. Types of reporting  1. change in shift report  It is a report given by a nurse to another due to change in shift  Provide continuity of care by providing quick summary of assigned patient  Includes diagnosis of patient, present health condition, treatment and medication.  Both the nurses while giving report should assess the patient together  Types : oral and written report
  • 47.  2. Telephone report  Include communication about patient’s transfer to another ward and about patient’s health status  Common – nurse to nurse, nurse to laboratory, nurse to physician  Telephone report should be documented, include time of call, who made the call and to whom information is given.
  • 48.  3. Transfer report  Related to shifting the patient from one unit to another  Transfer reports provide continuity of care by providing the information on telephone.  It include : Patient name, age and diagnosis. Current health status of patient Any procedure or intervention that need to be performed after transfer patient to other ward or unit.
  • 49.  4. Incident reports or Accident reports  Should be complete, clear and accurate as these are legal documents  Filled in the office of nursing superintendent  Studied for prevention of such accidents in future
  • 50.  5. Intra division report  Nurse incharge and bedside nurse  Between nurse incharge and physician  Head nurse and administrative supervisors
  • 51.  6. Inter department report  Reports shared with other department  Report of patient discharged are send to admission, business office and information desk
  • 52. Importance  Employer – Employment, promotion, disposition  Court of law for various purpose  Used for a job and leave from work place  Lawyers used for compensation and liability  Damage against negligent act  Execution of will  Medico-legal reasons  For use in consumer court
  • 53. Guideline – minimize legal liabilities  Patient identification data in all pages  Write clearly and appropriately  Facts should be based on the observation, conversation and action.  Select only relevant facts  Records should be neat, clean, complete and uniform  Record all telephonic conversation and follow up  Use standers terminologies and abbreviations  Do not erase or change any entries  No individual sheet should be separated  Correct all mistake as soon as possible  Record procedure after completion  Never leave vacant space  Do not write judgement comments  Do not destroy the documents
  • 54. Communication in health care team  Face to face communication  Written communication  Consultation  Referrals
  • 55. Nursing informatics  French word – informatique – computer science  The use of computers technology to support nursing, including clinical practice, administration, education and research
  • 56. Goal  To improve health of population, communities, families and individuals by optimizing, information management and communication  Use the technology in the direct provision of care, in establishing effective administrative system
  • 57. Functions  To enhance patient care and nursing practice  Way of keeping patient information properly organized  Nurses to make notes that every one can assess  Help with dosing instructions, staff assignment and lab results  Help and to create nursing care plan  Coordinated information help in decision making
  • 59. Importance of nursing informatics  Increase the accuracy and completeness of nursing documentation  Improves the nurses workflow  Eliminate redundant documentation  Automates the collection and reuse of nursing data  Facilitates analysis of clinical data  Access to resources and reference  Beneficial to nurses and interdisciplinary team  Administrative – support for cost saving and productivity goals
  • 60. Application  Nursing clinical practice – point of care system and clinical information system  Nursing administration  Nursing education nursing research